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Tobacco License Application CRF-008 - Georgia
|Tobacco License Application Form. This is a Georgia form and can be used in Alcohol And Tobacco Division Department Of Revenue Statewide .||
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Page 1 CRF-008 (Rev. 6/11) Georgia Department of Revenue Alcohol & Tobacco Division PO Box 49728 Atlanta, GA 30359 TOBACCO LICENSE APPLICATION 1 (877) 423-6711 FOR OFFICE USE ONLY (Read Instructions Before Completing) 1 2 3 4 5 STATE TAXPAYER IDENTIFIER: LEGAL BUSINESS NAME: TYPE OF LICENSE: (Check One) WHOLESALE RETAIL WHEN DID OR WILL YOU START SELLING TOBACCO PRODUCTS? KIND OF BUSINESS ENGAGED IN IF YOU ARE APPLYING FOR A WHOLESALE LICENSE, COMPLETE THE REMAINING QUESTIONS MANUFACTURER IMPORTER 6 7 8 WHAT WERE YOUR GROSS SALES OF TAXABLE CIGARS, CIGARETTES AND LOOSE OR SMOKELESS TOBACCO FOR THE PAST YEAR? DO YOU NOW OR DO YOU PLAN TO AFFIX THE CIGARETTE EXCISE STAMP? YES $ NO DOES THE PERSON MAKING APPLICATION HOLD A RETAIL CIGAR, CIGARETTE OR LOOSE AND SMOKELESS TOBACCO LICENSE? (If "YES", list name of retail business and retail license number) YES NO STI NUMBER RETAIL BUSINESS NAME TOBACCO LICENSE NUMBER 9 10 LIST ALL THE EMPLOYEES OF YOUR BUSINESS AND INDICATE THEIR POSITION AND SOCIAL SECURITY NUMBER NAME TITLE SOCIAL SECURITY NO. THIS APPLICATION HAS BEEN EXAMINED BY ME, AND TO THE BEST OF MY KNOWLEDGE IS TRUE AND CORRECT. SIGNATURE TITLE DATE (MUST BE SIGNED BY OWNER, PARTNER, OR AUTHORIZED OFFICER OF CORPORATION - STAMPED SIGNATURE ACCEPTABLE) FOR OFFICE USE ONLY TOTAL FEE PAID REGISTRATION STATUS REGISTRATION REASON STATE LICENSE NUMBER ISSUE DATE American LegalNet, Inc. www.FormsWorkFlow.com Page 2 CRF-008 (Rev. 6/11) Affidavit of Compliance with O.C.G.A. 50-36-1 "Verification of Lawful Presence within the United States" O.C.G.A. 50-36-1 requires that applicants applying for such things as licenses for public benefits complete a signed and sworn affidavit verifying the applicant's lawful presence in the United States. Therefore, the applicant must answer the following questions: The applicant is a United States citizen or legal permanent resident at least eighteen (18) years old. Yes ______ No ______ The applicant is a qualified alien or nonimmigrant under the federal Immigration and Nationality Act, Title 8 U.S.C., as amended, at least eighteen (18) years old, and is lawfully present in the United States. The applicant's alien number issued by the Department of Homeland Security or other federal immigration agency must be provided. Yes ______ No ______ Alien Number ____________________________________ O.C.G.A 50-36-1 states that "Any person who knowingly and willfully makes a false, fictitious, or fraudulent statement of representation in an affidavit executed pursuant to this Code section shall be guilty of a violation of Code Section 16-10-20." I declare, under penalty of law, that this affidavit has been completed by me and is true and correct. ___________________________________________________________________________________________ Signature Title Date (Must be signed by applicant. If the applicant is a corporation, must be signed by an officer of the corporation. STAMPED SIGNATURE IS NOT ACCEPTABLE) I hereby certify that__________________________________________________________ is personally known, or verified by me, that the applicant signed this application after stating to me his or her personal knowledge and understanding of all statements and, under oath actually administered by me, has sworn that the statements and answers contained in this affidavit are true. This _________ day of _____________, ______ . AFFIX SEAL _______________________________________ Notary Public You must attach a copy of a secure and verifiable document as defined in O.C.G.A. 50-36-2. Such documents include a valid Georgia issued Driver's License or ID Card, a valid Driver's License issued by another State or an identification document issued by the United States Government. American LegalNet, Inc. www.FormsWorkFlow.com Page 3 CRF-008 (Rev. 6/11) STATE OF GEORGIA DEPARTMENT OF REVENUE INSTRUCTIONS FOR COMPLETION OF THE TOBACCO LICENSE APPLICATION (CRF-008) Use this form to apply for a Tobacco License. Every person, firm, or corporation desiring to engage in or conduct the business of manufacturing, purchasing, selling, consigning, vending, dealing in, or distributing cigars, cigarettes or loose and smokeless tobacco in the State of Georgia is required to obtain a Tobacco License. No person shall hold a wholesale license and a retail license at the same time. TYPE OR PRINT IN INK DO NOT USE PENCIL A: INSTRUCTIONS FOR COMPLETING: Line 1- Enter your Georgia State Taxpayer Identifier. If you do not have a State Taxpayer Identification Number you must also complete a CRF-002. Line 2- Enter the name under which your business is legally registered with the Secretary of State. If your business is not registered, then enter the name under which your business owns property or acquires debt. If the business is a partnership, the legal name is the partnership name. In the case of a sole proprietorship, the legal name is the individual owner of the business. Line 3- Check the type of license for which you are applying. Line 4- Enter the date (MMDDYYY) you began or will begin selling tobacco products. Line 5- Describe the type of business you are engaged in, i.e., grocery store, newsstand, pipe and tobacco store, convenience store, etc. Complete Line 6-10 only if you are applying for a wholesale tobacco license. Line 6- Enter the amount of your gross tobacco sales for the past fiscal year. If new business, enter zero (0). Line 7- Check "yes" or "no" in spaces provided. Line 8- Check "yes" or "no" in spaces provided. Line 9- If "yes" answered in Line 8; provide the Georgia State Taxpayer Identifier, legal business name, and the tobacco license number of the retail business. Line 10- List all persons you employ in this business and their respective positions. For each manufacturer's representative and wholesaler salesman, you must also complete an Application for Tobacco Permit- ATT-12. B: INSTRUCTIONS FOR SIGNING: This application must be signed by the owner, a partner, or an authorized officer of the corporation. C: INSTRUCTIONS FOR PAYMENT: There is no registration or license fee for a retail tobacco license. The annual license fee for a wholesale distributor, manufacturer or importer of cigars, cigarettes or loose and smokeless tobacco is $50.00 except that for a person commencing business for the first time, the first year license fee is $250.00. A cashier's check, money order, or a certified check for the appropriate fee must be made payable to the GEORGIA REVENUE COLLECTION ACCOUNT.